HomeMy WebLinkAbout644 GILGALAD WAY - APPLICATIONS - 10/21/20111)-21-11;14:34 ;From:rtn roofing
To:2246134 ;9705931119 * 2/ 2
City Of Planning, Development & Transportation
® Collins 281 N. College Ave P.O. Box 580
Fart Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNITER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical. Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement q Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # 3 1 1 0 9 S1 X
For office use only
Date J'0ZL-2-1.J ( t ) 0 t. aS
lob Site Address (required)
_J6(
Value of Construction (labor, materials, profit)
-3, DO
6LI4 60aia�'all,
0 00,
Property Owner Nant4 i�ddress
City/State Zip
Phone
Gar Oz-2e l o (r(li( G' I 4Ala
I is o irlc CD S�05
70-222-3K1
Applicant Name Ad ress
City/State Zip
Phone
Self LozoK 5'g5 ' I cc. � -e� > LOve-(A0J. CO $V 53
70-6 7-1(oa
Contractor Address
City/State Zp
Phone
e' rJ
A
Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report?
trust
,IHere O Report
❑ Yes No
saiestaxnumber tsrequhrdbyit/ contrracmr✓.
3��50
Are you paying with your account?
Is this a residential or commercial project? P(.Resldential ❑ commercial
If residential, is it; Single Family Detached Condo/tow6hbme (single family attached) ` ❑ Duplex
0❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank O Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building So years of age or more? ❑ Yes ONO If yes, you may need to contact Historic Preseivatlon
If this Is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work ee rvt ov%e n d t e-p t a e ����`ro ':30 s GI i nc I d < .
u
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: L& the company name or aty of Ft Collins license 0
Electrician Plumber Mechanical Roofer a i Other
I hereby acknowledge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances.and.state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant: nn nn��jj /
Print Name: r I5fi01�lCrI fQlntt/lsignature
i Date / D a / /I